Thoughts on the status of the Reorientation Wars

So now that the dust has started to settle from the APA convention in Toronto, let’s review the status of the Reorientation Wars.

Does therapy change orientation?

In anticipation of the APA’s report, NARTH fired an opening salvo with their paper (What Research Shows…). Perhaps sensing, incorrectly as it turns out, that the APA would advocate a ban on reorientation therapy, NARTH tossed every positive reference to change they could find into the paper. They noted problems in defining sexual orientation but did little to distinguish the various definitions and their meaning in the many studies they cited. They concluded, of course, that therapy can change orientation.

The APA on the other hand, differentiated sexual orientation and sexual orientation identity. Sexual orientation for them is the biological responsiveness to one gender or both. According to their literature review, the evidence that therapy can change orientation is not sufficient to permit therapists to inform clients that therapy can change their orientation. However, sexual orientation identity (i.e., self-labeling) may shift and be responsive to a variety of factors, including religious mediation.

It seems to me that what NARTH is calling sexual orientation includes the APA’s sexual orientation identity. While this statement risks taking us into the “all or nothing” dead end discussion about change, I do not mean that one must change completely for change to be important and psychologically relevant. I suggest instead that what many studies measure is how people see themselves, even if their sexual responsiveness (orientation) has only shifted by a degree (e.g., an average of less than a point on the Kinsey scale in the Jones and Yarhouse study). Jones and Yarhouse suggest as much in their recent paper when they write:

There is also the question of sexual identity change versus sexual orientation change (see Worthington & Reynolds, 2009). Recent theoretical (e.g., Yarhouse, 2001) and empirical (e.g., Beckstead & Morrow, 2004; Yarhouse & Tan, 2004; Yarhouse, Tan & Pawlowski, 2005; Wolkomir, 2006) work on sexual identity among religious sexual minorities suggests that attributions and meaning are critical in the decision to integrate same-sex attractions into a gay identity or the decision to dis-identify with a gay identity and the persons and institutions that support a gay identity. In light of the role of attributions and meaning in sexual identity labeling, is it possible that some of what is reported in this study as change of orientation is more accurately understood as change in sexual identity?

I believe the answer to their question is that it is not only possible but probable that change in sexual identity is what is being reported. The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction. I also believe that men and women are different and their change may be different. Women seem to describe less exclusivity than men. Fluidity may be more likely with complete shifts described. I think we need to accommodate atypical experiences such as men and women who completely shift for a time and then shift back. Whatever the pattern, I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways.

Is sexual reorientation harmful or beneficial?

NARTH says reorientation might harm some people but that for the most part it is not harmful. The APA says existing studies are not good enough to allow conclusions. Point for the APA here. All we can say is that some people report harm and some people report benefit. The APA notes that the benefits can occur in programs which promote congruence with religious faith. This is clear and the Jones and Yarhouse study demonstrate that health status improves modestly for those who remained in the study. However, I would say we do not yet know much about what the potent or beneficial elements of those programs are. The APA report identified some of those elements.

Homosexuality and pathology

NARTH says homosexuals have more pathology than any other group of similar size. The APA says homosexuality is normal. By this they mean that homosexuality is not a developmental disorder or indicator of a mental disorder. The two recent reports go off in different directions but some observations can be made.

The NARTH report spends lots of time reporting on greater levels of mental health and health problems among homosexuals as compared to heterosexuals. The APA report does not do this. However, I believe the point regarding different levels of symptoms would be stipulated by the APA. However, the APA raises the minority stress model as responsible for many difficulties faced by non-heterosexual people. The NARTH report discounts the role of stigma.

I doubt the APA would dispute the health status data for another reason: greater group pathology does not mean inherent disorder. The APA’s position is not that gays have equal health outcomes but rather that the unequal health outcomes do not imply inherent pathology – that SSA is not inherently the result of pathological development. This is of course in great contrast to the reparative therapists. Joseph Nicolosi says that the only way you get SSA is to traumatize a child.

The reparative impulse to find trauma behind every gay person is misguided I believe, conceptually and for sure empirically. Women have greater levels of mental health problems than men but we would not consider women inherently disordered. NARTH has chosen some good studies to cite in the section of their paper which relates to health status (as well as some really bad and irrelevant ones). However, I don’t think it really gets them where they want to go.

And where do they want to go? This is clear from their press release complaining about the APA task force report. They state:

Further, if some clients are dissatisfied with the therapeutic outcome [of reorientation therapy], as in therapy for other issues, the possibility for dissatisfaction appears to be outweighed by the potential gains. The possibility of dissatisfaction also seems insignificant when compared to the substantial medical, emotional, and physical risks associated with homosexual behavior.

NARTH would suggest that these medical and emotional risks, along with the incongruity of homosexual behavior with the personal and religious values of many people will continue to be the motivation for some individuals to seek assistance for their unwanted homosexual attraction.

According to NARTH, gays ought to seek reorientation therapy because being gay is a risky life, full of health and mental health disadvantages. Their hypothesis is implied but hard to miss: reduce the SSA and reduce the health risks. The assumption appears to be that ex-gays will have better health outcomes than gays. One problem with this line of thinking is that there is no empirical evidence for it and some evidence against it.*

One researcher quoted in the NARTH paper regarding health risks was New Zealand’s David Fergusson. Dr. Fergusson has done significant work in this field. I asked him to look at the section of the NARTH paper in which his work was quoted. Here is a statement he provided about it:

While the NARTH statement provides a comprehensive and accurate analysis of the linkages between sexual orientation and mental health, the paper falls far short of demonstrating that homosexuality should be classified as a psychiatric disorder that may be resolved by appropriate therapy. To demonstrate this thesis requires an in depth understanding of the biological and social pathways that explain the linkages between homosexual orientation and mental health. At present we lack that understanding. Furthermore it is potentially misleading to treat what may be a correlate of mental disorder as though it were a disorder in its own right.

Fergusson also told me that one would need to develop studies to demonstrate that any changes in orientation associate with improvements in health status. The Jones and Yarhouse study provide some very general assessment but many potential confounds are uncontrolled. For instance, it is not possible to say that the modest shifts on the Kinsey scale were responsible for the shifts in health status. These folks were quite religious and religion is associated with enhanced health status. I suspect religious gays have a better health status than non-religious gays, on average. The point is we do not have evidence that sexual orientation status per se is what leads to the differences in health status.

While I am on the subject of health status, I need to mention that there are other factors which NARTH ignored. One, gender non-conformity is strongly correlated with adult homosexuality and is also associated with poorer mental health. Two, homosexuals report higher levels of sexual victimization which is also associated with higher levels of mental health problems. And, three, no one can discount the possibility that biological factors which associate with the development of homosexuality may also influence the development of emotional problems (i.e., in the same way women are more likely to report depression than men).

So where are we? I hope we have a larger middle and smaller numbers of people at the opinion extremes. People on both sides can agree that erotic responsiveness is extremely durable for men and perhaps less so for women, but behavior and self-identity reflection is alterable. People on both sides agree that conclusions about benefit and harm are not possible in any general sense. Also, I hope we can agree that full informed consent should be conducted prior to engaging in counseling. Regarding health status, both sides can agree that homosexuals have higher levels of problems but there is little agreement about what the differences mean.

Those on the far sides of the continuum will continue to argue that change is possible or change is impossible, and/or that reorientation is always harmful or never harmful and/or that health status difference mean something vital or irrelevant about inherent pathology.

The wars will continue but perhaps fewer people will be engaged in them; now is the time rather to reason together.

*Nottebaum, L. J., Schaeffer, K. W., Rood, J., & Leffler, D. (2000). Sexual orientation—A comparison study. Manuscript submitted for publication. (Available from Kim Schaeffer, Department of Psychology, Point Loma Nazarene University, 3900 Lomaland Drive, San Diego, CA 92106) – In this study, the authors found that mental health was better among the gay sample than the Exodus sample.

Get Religion discusses media coverage of the APA report

The Get Religion blog has two entries up today discussing media coverage of the APA sexual orientation and therapy report. The first one deals with the articles by the Associated Press, Washington Times, and Baptist Press.

The second one hearts the Wall Street Journal article by Stephanie Simon which discusses the sexual identity therapy framework and the APA report.

FYI

Jones and Yarhouse Exodus study follow up

This morning at the American Psychological Association annual convention, Stanton Jones and Mark Yarhouse are presenting their Time 6 and final follow up to the study of Exodus participants seeking change of orientation. The paper is titled, Ex Gays? An Extended Longitudinal Study of Attempted Religiously Mediated Change in Sexual Orientation. They are presenting these data as a part of a APA symposium titled Sexual Orientation and Faith Tradition Symposium chaired by Dean Byrd.

You can review the paper in full so I will only highlight a few points in the post.

The paper begins by recounting the skepticism toward change evinced by the professional mental health associations. Then, they note an important limit and hypotheses of the study:

Our study addresses the generic questions of whether sexual orientation is changeable, and whether the attempt is intrinsically harmful, by focusing only on the religiously mediated approaches to change; this is not a study of professional psychotherapy. Our hypotheses for this study were taken directly from the prevailing professional wisdom: We hypothesized 1) sexual orientation is not changeable, and 2) the attempt to change is likely harmful. We already cited the American Psychological Association’s (2005) claim that sexual orientation “is not changeable.” Regarding harm, our study was framed in light of the American Psychiatric Association’s (1998) claim that the “potential risks of ‘reparative therapy’ are great, including depression, anxiety and self-destructive behavior.” The tools of scientific study are ideally suited to investigate empirically such strong, even absolute claims.

I bolded the statement about the study not being an examination of psychotherapy because I predict that NARTH affiliated therapists and various religious conservative groups will not clearly communicate this point when messaging the results of this study. Despite the fact that Christian self-help groups are different than therapy as practiced by many psychodynamic therapists, I suspect some therapists will hope the public does not catch the distinction.

Now for some results. Retention is sure to be an issue as this study is discussed:

Retention. We began with 98 subjects at T1. Our sample eroded to 73 at T3, a retention rate of 74.5%. This retention rate compares favorably to that of respected longitudinal studies. 63 subjects were interviewed or categorized at T6, for a T1 to T6 6 to 7 year retention of 64%.

Kinsey scale changes:

Table 1

This table shows the shifts in Kinsey scale scores (7 is exclusively homosexual with 1 being exclusively heterosexual). You can see that the shifts on average were about a point on the scale – less than one for the entire group and more than one for the group which were deemed more gay identified at the beginning. Although statistically significant, this would not on average take the group to the straight side of the continuum but rather by considered bisexual by most observers.

They also used the Shively-DeCecco scale which asks participants to rand both same-sex attraction and opposite-sex attraction. As you can see below, the change reflected in the Kinsey moves was due to reductions in SSA and not increases in OSA.

Table 2

Regarding categorical self-assessments, Jones and Yarhouse report modest shifts.

Table 5

Regarding these changes, Jones and Yarhouse say:

Several results are particularly notable. Despite a smaller N for the T6 sample than at T3, we found growth in absolute size in the two Exodus “success” outcome groups moving from row 1 to row 3: Conversion cases grew from 11 to 14 and Chastity cases from 17 to 18. But the group that grew the most in absolute and proportional terms was Failure: Gay Identity which doubled in absolute size from 6 to 12. The percentage of those showing stability of outcome T3 to T6 (row 4) is greatest in columns 1 and 6: the Success: Conversion (73%) and Failure: Gay Identity (67%) categories, with slightly less in the Success: Chastity category (53%). Of the one subject each that shifted from the Success: Conversion and Failure: Gay Identity categories from T3 to T6, each moved to the Continuing category at T6. The largest absolute shift from T3 to T6 of those who participated in the T6 interview was a T3 Success: Chastity case that became a Failure: Gay Identity case; next largest was a Non-Response case at T3 that became a Success: Conversion case.

Most germane to our principal hypothesis that change of sexual orientation is not possible, 53% of the T6 sample of 61 cases that self-categorized (row 3) did so as some version of success, either as Success: Conversion (23%) or Success: Chastity (30%). At T6, 25% of the sample self-categorized as an Exodus failure (Confused or Gay Identity).

In my view, this means of description confuses success with change. Over half did describe some version of success but that is not the same as over half describing sexual orientation change. I will be interested to see how this is reported in the press.

The changes reported here are significant and no doubt welcomed by the people involved. However, they are not the types of changes which I suspect the various mental health groups mean by “sexual orientation change.” Whatever happened to the participants in this study, they do not appear to have gone from gay to straight — in the sense that people who have always been straight are straight. They have gone from gay to less gay and a bit more straight. I do not mean to suggest that this is not important information; it is. But I am wondering if anyone at APA would dispute the within category changes reported here. I am going to ask and will report what I learn.

Jones and Yarhouse seem to be aware that the results can be understood as a change in identity and not orientation. They write:

There is also the question of sexual identity change versus sexual orientation change (see Worthington & Reynolds, 2009). Recent theoretical (e.g., Yarhouse, 2001) and empirical (e.g., Beckstead & Morrow, 2004; Yarhouse & Tan, 2004; Yarhouse, Tan & Pawlowski, 2005; Wolkomir, 2006) work on sexual identity among religious sexual minorities suggests that attributions and meaning are critical in the decision to integrate same-sex attractions into a gay identity or the decision to dis-identify with a gay identity and the persons and institutions that support a gay identity. In light of the role of attributions and meaning in sexual identity labeling, is it possible that some of what is reported in this study as change of orientation is more accurately understood as change in sexual identity?

The entire section on identity and orientation in the discussion section of the paper is good reading. Finally, in light of the APA task force report, I wonder if the discussion section of the Jones and Yarhouse paper could be revisited. The APA report, while skeptical of categorical change, did not take a strong stance regarding harm. Actually, the APA report and the Jones and Yarhouse paper agree on the inconclusive nature of the evidence on that question.

Media reports regarding the APA sexual orientation and therapy report

In addition to the separate posts on the topic, here is some additional coverage. If time permits, I may add a comment or two of opinion to them.

USA Today

Christianity Today

World Magazine

Mother Jones

AP Radio Network

Associated Press

Los Angeles Times

Southern Voice

The Advocate

Citizenlink, Day 1

Citizenlink, Day 2

Washington Times

CBN reports on APA report

The Christian Broadcasting Network reports this morning on the APA task force findings.

UPDATE: The video now does not reflect the news report linked above.